LCD/NCD Portal

L28843

 

FLUORESCEIN ANGIOGRAPHY

 

02/02/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Medicare Part B will consider fluorescein angiography medically reasonable and necessary for the following conditions: (See ICD-9 Codes That Support Medical Necessity).

• Initial evaluation of a patient with abnormal findings of the fundus/retina on an ophthalmoscopy exam, not limited to the following:

o Choroidal Neovascular Membranes (CNVM)-these appear as a round to oval, greenish-gray lesion(s).

o Lesions of the Retinal Pigment Epithelium (RPE)

 Serous detachment of the RPE appears as a round or oval, yellow-orange, sharply demarcated mound.

 Tears or rips of the RPE.

 A hemorrhagic detachment will appear as a dark green or red, discretely elevated mound.

o Fibrovascular disciform scar-these lesions vary in color from white to yellow to brown to black depending upon the degree of retinal pigment epithelial hypertrophy.

o Vitreous hemorrhage-patient presents with complaints of sudden vision loss

o Drusen-appears as pale yellow spots beneath the RPE and represent the earliest clinically detectable feature of age related macular degeneration.

• Evaluation of a patient presenting with symptoms such as sudden vision loss, especially central vision, blurred vision, distortion, etc. which may suggest that a subretinal neovascularization is present.

• Evaluation of patients with nonproliferative (background) and proliferative diabetic retinopathy with or without macular edema.

o Background retinopathy is characterized by intraretinal microaneurysms, hemorrhages, nerve-fiber-layer infarcts, hard exudates and microvascular abnormalities.

o Proliferative retinopathy is characterized by neovascularization arising either from the disk or from the retinal vessels.

o Frequency of the fluorescein angiography is dependent on the extent of the disease progression and the treatment performed (i.e., photocoagulation).

o Fluorescein angiography may be performed on the treated eye only at 6 weeks post=treatment and as often as every 8-12 weeks to assist in management of the retinopathy.

• Evaluation of patients with:

o Chorioretinitis.

o Chorioretinal scars of choroidal degeneration.

o Dystrophies.

o Hemorrhage and rupture.

o Detachment.

• Evaluation of patients with known retinal or macular disorders such as:

o Age-related macular degeneration (ARMD).

o ARMD is the leading cause of permanent blindness in the elderly.

o The disease includes a broad spectrum of clinical and pathologic findings that can be classified into two groups: nonexudative (“dry”) and exudative (“wet”).

o Although patients with ARMD usually manifest nonexudative changes only, the majority of patients who experience severe vision loss from this disease do so from the development of subretinal neovascularization and related exudative maculopathy.

• The management of these two groups differs.

o Follow-up examination of the treated eye after laser coagulation for exudative macular degeneration is recommended at:

 1-2 weeks.

 1 month.

 6 weeks.

 Then every 6-12 months unless:

• New symptomatology. (i.e., sudden central vision loss, distortion).

• Recurrence of subretinal neovascularization (as demonstrated by fluorescein) exists.

o If recurrent leakage is noted, laser therapy will be repeated, and the fluorescein angiography and fundus photography series will be repeated.

• Eyes with the nonexudative form of macular degeneration should have regular ophthalmic examinations, including fluorescein angiography performed every 6-12 months since the exudative stage may develop suddenly at any time even before patients demonstrate symptomatic visual problems.

o Macular edema secondary to diabetic retinopathy.

o Cystoid Macular Edema-caused by fluid accumulating in honeycomb-like spaces of the outer plexiform and inner nuclear layers.

 On Fluorescein angiography, the dye leaks from the perifoveal retinal capillaries and accumulates in a flower-petal pattern about the fovea.

o Central Retinal Vein Occlusion is a common and easily diagnosed retinal vascular disorder with potentially blinding complications (macular edema and neovascular glaucoma secondary to iris neovascularization).

 Most eyes will have persistent decreased central vision as a result of chronic macular edema.

 Fluorescein angiography demonstrates significant retinal capillary nonperfusion in 1/3 of the eyes. Treatment and follow-up are dependent on severity of disease.

o Branch Retinal Vein Occlusion presents as sudden unilateral vision loss with segmentally distributed intraretinal hemorrhage.

 Sight-threatening complications of the disease are macular edema, macular ischemia and vitreous hemorrhage from retinal neovascularization.

 Treatment and follow-up of this disease are dependent on the severity.

• The Fluorescein angiography and fundus photography are normally performed together.

o These studies should be performed no greater than 72 hours prior to laser therapy for ARMD because abnormal blood vessels grow at rapid rates making the studies older than 72 hours inadequate to guide laser treatment.

Coding Information

 

Bill Type Codes

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

14x Hospital - Laboratory Services Provided to Non-patients

21x Skilled Nursing - Inpatient (Including Medicare Part A)

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

71x Clinic - Rural Health

 

Revenue Codes

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

0510 Clinic - General Classification

0511 Clinic - Chronic Pain Center

0512 Clinic - Dental Clinic

0513 Clinic - Psychiatric Clinic

0514 Clinic - OB-GYN Clinic

0515 Clinic - Pediatric Clinic

0516 Clinic - Urgent Care Clinic

0517 Clinic - Family Practice Clinic

0519 Clinic - Other Clinic

0920 Other Diagnostic Services - General Classification

 

 

CPT/HCPCS Codes

 

 

92235 FLUORESCEIN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) WITH INTERPRETATION AND REPORT

 

 

ICD-9 Codes that Support Medical Necessity

 

 

115.02 HISTOPLASMA CAPSULATUM RETINITIS

115.92 HISTOPLASMOSIS RETINITIS UNSPECIFIED

130.2 CHORIORETINITIS DUE TO TOXOPLASMOSIS

135 SARCOIDOSIS

190.5 MALIGNANT NEOPLASM OF RETINA

190.6 MALIGNANT NEOPLASM OF CHOROID

224.5 BENIGN NEOPLASM OF RETINA

224.6 BENIGN NEOPLASM OF CHOROID

228.03 HEMANGIOMA OF RETINA

250.50 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.51 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.52 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

250.53 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

360.00 PURULENT ENDOPHTHALMITIS UNSPECIFIED

360.01 ACUTE ENDOPHTHALMITIS

360.02 PANOPHTHALMITIS

360.03 CHRONIC ENDOPHTHALMITIS

360.11 SYMPATHETIC UVEITIS

360.12 PANUVEITIS

360.13 PARASITIC ENDOPHTHALMITIS UNSPECIFIED

360.14 OPHTHALMIA NODOSA

360.20 DEGENERATIVE DISORDER OF GLOBE UNSPECIFIED

360.21 PROGRESSIVE HIGH (DEGENERATIVE) MYOPIA

360.23 SIDEROSIS OF GLOBE

360.24 OTHER METALLOSIS OF GLOBE

360.55 FOREIGN BODY MAGNETIC IN POSTERIOR WALL

360.65 FOREIGN BODY IN POSTERIOR WALL OF EYE

361.2 SEROUS RETINAL DETACH

362.01 BACKGROUND DIABETIC RETINOPATHY

362.02 PROLIFERATIVE DIABETIC RETINOPATHY

362.03 NONPROLIFERATIVE DIABETIC RETINOPATHY NOS

362.04 MILD NONPROLIFERATIVE DIABETIC RETINOPATHY

362.05 MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY

362.06 SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY

362.07* DIABETIC MACULAR EDEMA

362.10 BACKGROUND RETINOPATHY UNSPECIFIED

362.11 HYPERTENSIVE RETINOPATHY

362.12 EXUDATIVE RETINOPATHY

362.13 CHANGES IN VASCULAR APPEARANCE OF RETINA

362.14 RETINAL MICROANEURYSMS NOS

362.15 RETINAL TELANGIECTASIA

362.16 RETINAL NEOVASCULARIZATION NOS

362.17 OTHER INTRARETINAL MICROVASCULAR ABNORMALITIES

362.18 RETINAL VASCULITIS

362.21 RETROLENTAL FIBROPLASIA

362.22 RETINOPATHY OF PREMATURITY, STAGE 0

362.23 RETINOPATHY OF PREMATURITY, STAGE 1

362.24 RETINOPATHY OF PREMATURITY, STAGE 2

362.25 RETINOPATHY OF PREMATURITY, STAGE 3

362.26 RETINOPATHY OF PREMATURITY, STAGE 4

362.27 RETINOPATHY OF PREMATURITY, STAGE 5

362.29 OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY

362.30 RETINAL VASCULAR OCCLUSION UNSPECIFIED

362.31 CENTRAL RETINAL ARTERY OCCLUSION

362.32 RETINAL ARTERIAL BRANCH OCCLUSION

362.33 PARTIAL RETINAL ARTERIAL OCCLUSION

362.34 TRANSIENT RETINAL ARTERIAL OCCLUSION

362.35 CENTRAL RETINAL VEIN OCCLUSION

362.36 VENOUS TRIBUTARY (BRANCH) OCCLUSION OF RETINA

362.37 VENOUS ENGORGEMENT OF RETINA

362.40 RETINAL LAYER SEPARATION UNSPECIFIED

362.41 CENTRAL SEROUS RETINOPATHY

362.42 SEROUS DETACH OF RETINAL PIGMENT EPITHELIUM

362.43 HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM

362.51 NONEXUDATIVE SENILE MACULAR DEGENERATION OF RETINA

362.52 EXUDATIVE SENILE MACULAR DEGENERATION OF RETINA

362.53 CYSTOID MACULAR DEGENERATION OF RETINA

362.54 MACULAR CYST HOLE OR PSEUDOHOLE OF RETINA

362.55 TOXIC MACULOPATHY OF RETINA

362.56 MACULAR PUCKERING OF RETINA

362.57 DRUSEN (DEGENERATIVE) OF RETINA

362.65 SECONDARY PIGMENTARY DEGENERATION OF RETINA

362.66 SECONDARY VITREORETINAL DEGENERATIONS

362.70 HEREDITARY RETINAL DYSTROPHY UNSPECIFIED

362.71 RETINAL DYSTROPHY IN SYSTEMIC OR CEREBRORETINAL LIPIDOSES

362.72 RETINAL DYSTROPHY IN OTHER SYSTEMIC DISORDERS AND SYNDROMES

362.73 VITREORETINAL DYSTROPHIES

362.74 PIGMENTARY RETINAL DYSTROPHY

362.75 OTHER DYSTROPHIES PRIMARILY INVOLVING THE SENSORY RETINA

362.76 DYSTROPHIES PRIMARILY INVOLVING THE RETINAL PIGMENT EPITHELIUM

362.77 RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE

362.81 RETINAL HEMORRHAGE

362.82 RETINAL EXUDATES AND DEPOSITS

362.83 RETINAL EDEMA

362.84 RETINAL ISCHEMIA

362.85 RETINAL NERVE FIBER BUNDLE DEFECTS

363.00 FOCAL CHORIORETINITIS UNSPECIFIED

363.01 FOCAL CHOROIDITIS AND CHORIORETINITIS JUXTAPAPILLARY

363.03 FOCAL CHOROIDITIS AND CHORIORETINITIS OF OTHER POSTERIOR POLE

363.04 FOCAL CHOROIDITIS AND CHORIORETINITIS PERIPHERAL

363.05 FOCAL RETINITIS AND RETINOCHOROIDITIS JUXTAPAPILLARY

363.06 FOCAL RETINITIS AND RETINOCHOROIDITIS MACULAR OR PARAMACULAR

363.07 FOCAL RETINITIS AND RETINOCHOROIDITIS OF OTHER POSTERIOR POLE

363.08 FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL

363.10 DISSEMINATED CHORIORETINITIS UNSPECIFIED

363.11 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS POSTERIOR POLE

363.12 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS PERIPHERAL

363.13 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS GENERALIZED

363.14 DISSEMINATED RETINITIS AND RETINOCHOROIDITIS METASTATIC

363.15 DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY

363.20 CHORIORETINITIS UNSPECIFIED

363.21 PARS PLANITIS

363.22 HARADA'S DISEASE

363.30 CHORIORETINAL SCAR UNSPECIFIED

363.31 SOLAR RETINOPATHY

363.32 OTHER MACULAR SCARS OF RETINA

363.33 OTHER SCARS OF POSTERIOR POLE OF RETINA

363.34 PERIPHERAL SCARS OF RETINA

363.35 DISSEMINATED SCARS OF RETINA

363.40 CHOROIDAL DEGENERATION UNSPECIFIED

363.41 SENILE ATROPHY OF CHOROID

363.42 DIFFUSE SECONDARY ATROPHY OF CHOROID

363.43 ANGIOID STREAKS OF CHOROID

363.50 HEREDITARY CHOROIDAL DYSTROPHY OR ATROPHY UNSPECIFIED

363.51 CIRCUMPAPILLARY DYSTROPHY OF CHOROID PARTIAL

363.52 CIRCUMPAPILLARY DYSTROPHY OF CHOROID TOTAL

363.53 CENTRAL DYSTROPHY OF CHOROID PARTIAL

363.54 CENTRAL CHOROIDAL ATROPHY TOTAL

363.55 CHOROIDEREMIA

363.56 OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID PARTIAL

363.57 OTHER DIFFUSE OR GENERALIZED DYSTROPHY OF CHOROID TOTAL

363.61 CHOROIDAL HEMORRHAGE UNSPECIFIED

363.62 EXPULSIVE CHOROIDAL HEMORRHAGE

363.63 CHOROIDAL RUPTURE

363.70 CHOROIDAL DETACH UNSPECIFIED

363.71 SEROUS CHOROIDAL DETACH

363.72 HEMORRHAGIC CHOROIDAL DETACH

364.24 VOGT-KOYANAGI SYNDROME

364.42 RUBEOSIS IRIDIS

368.11 SUDDEN VISUAL LOSS

377.00 PAPILLEDEMA UNSPECIFIED

377.01 PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE

377.02 PAPILLEDEMA ASSOCIATED WITH DECREASED OCULAR PRESSURE

377.03 PAPILLEDEMA ASSOCIATED WITH RETINAL DISORDER

377.04 FOSTER-KENNEDY SYNDROME

377.16 HEREDITARY OPTIC ATROPHY

377.21 DRUSEN OF OPTIC DISC

377.22 CRATER-LIKE HOLES OF OPTIC DISC

377.23 COLOBOMA OF OPTIC DISC

377.24 PSEUDOPAPILLEDEMA

377.30 OPTIC NEURITIS UNSPECIFIED

377.31 OPTIC PAPILLITIS

377.32 RETROBULBAR NEURITIS (ACUTE)

377.33 NUTRITIONAL OPTIC NEUROPATHY

377.34 TOXIC OPTIC NEUROPATHY

377.41 ISCHEMIC OPTIC NEUROPATHY

377.42 HEMORRHAGE IN OPTIC NERVE SHEATHS

377.43 OPTIC NERVE HYPOPLASIA

377.49 OTHER DISORDERS OF OPTIC NERVE

379.07 POSTERIOR SCLERITIS

379.22 CRYSTALLINE DEPOSITS IN VITREOUS

794.11 NONSPECIFIC ABNORMAL RETINAL FUNCTION STUDIES

* ICD-9-CM code 362.07 requires a dual diagnosis. When using ICD-9-CM code 362.07 (diabetic macular edema) a code for diabetic retinopathy (362.01-362.06) must also be used.

 

 

Documentation Requirements

• Medical Record Documentation maintained by the performing physician must indicate the medical necessity of the fluorescein angiography for each eye.

• Office records/progress notes must document the complaint, symptomatology, or reason necessitating the test and must include the examination results/findings.

 

Treatment Logic

• Fluorescein angiography plays an important role in ophthalmoscopic diagnosis especially in diagnosing and evaluating of many retinal conditions.

• It has the ability to precisely delineate areas of abnormality, and is an essential guide for planning laser treatment of retinal vascular disease.

• Fluorescein angiography is performed by intravascular injection or oral administration of a contrast solution of sodium fluorescein.

• Ophthalmoscopy performed in conjunction with fluorescein angiography using a blue filter to excite the fluorescein is useful in detecting leaking capillaries (subretinal neovascularization).

• The presence of a permanent record is valuable in the determination of disease progression.

• Multiple black and white photographs of the ocular fundus at different times following fluorescein injection provides much information concerning vascular obstructions, neovascularization, microaneurysms, abnormal capillary permeability, and defects of the retinal pigment epithelium.

• Normal values of a fluorescein angiogram include normal retinal vessels, retina, and choroidal circulation.

 

Sources of Information and Basis for Decision

 

Bennett, T. The Fundamentals of Fluorescein Angiography. The Ophthalmic Photographers’ Society, Inc. Retrieved from http://www.opsweb.org/Op-Photo/angio/FA/FA1.htm on July 15, 2005.

 

FCSO LCD 29177, Fluorescein Angiography, 02/02/2009. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Medline Plus Medical Encyclopedia. Fluorescein Angiography. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003846.htm on July 27, 2005.

 

Miller, R. (2005). Miller’s Anesthesia, sixth edition. Pages 2997-2998, Elsevier.

 

Yanoff, M; Duker, J; Azar, D. et al Eds (2004). Ophthalmology, Second edition. Pages 800-805, Mosby’s.

 

 

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

CMS LCD L28843 Fluorescein Angiography